Maryland's insurance regulator issued a bulletin Tuesday clarifying that while insurance policies in the state do not have to cover treatments related to gender reassignment, insurance carriers cannot discriminate against transgender Marylanders based on their gender identities.

In the plan, the Maryland Insurance Administration allowed insurers to exclude "treatment leading to or in connection with transsexualism, or sex changes or modifications" including sexual reassignment surgery.

Tuesday's bulletin specifies the exclusion cannot be used to deny coverage for services or items to transgender policyholders "on the basis of [their] actual or perceived gender identity."

The Maryland Insurance Administration's bulletin is similar to a clarification issued by the federal Department of Health and Human Services (HHS) in 2012. At the time, HHS confirmed the Affordable Care Act's anti-discrimination protections also forbid discrimination on the basis of gender identity.

According to the bulletin, the essential benefit benchmark plan's exclusion can still be applied to "items and services that are directly related to the gender reassignment process."

Currently, insurance commissioners in five other states and the District of Columbia require policies issued in their jurisdictions to cover transition-related health services if they cover those same treatments for other medical conditions.